Targeted Therapeutics in Biliary Tract Cancer

Hepatocellular Carcinoma

William P. Harris, MDAssociate Professor, Medical Oncology, University of Washington

Associate Member, Clinical Research Division, Fred Hutchinson Cancer Research Center

Disclosures:

• Institutional Research Funding: Agios, Basilea, Bayer, BTG, BMS, Merck, Medimmune, Exelixis

• Consulting: Eisai, Zymeworks

• Other Unpaid Affiliations: GI Cancer Alliance, ASCO, Fibrolamellar Cancer Foundation

El-Serag HB. N Engl J Med 2011;365:1118-1127.

Bray et al. Cancer 2018:68(6) 394-424

3rd leading cause of global cancer related death Incidence and mortality is rising in the United States

HCC: Global incidence

Diabetes MellitusObesity

HCC: Risk Factors

• Cirrhosis from any cause (3-4%annual risk of HCC)

• HCV • HBV• Heavy alcohol consumption• Non-alcoholic steatohepatitis (NASH)• Aflatoxins

• HBV Chronic Hepatitis (0.4% annual risk of HCC)

• Inherited metabolic diseases• Hemochromatosis • Alpha-1 antitrypsin deficiency • Glycogen storage disease• Porphyria cutanea tarda• Tyrosinemia • Autoimmune hepatitis

HCC: Screening and Early Detection• Approximately 19,000 patients with chronic hepatitis/chronic HBV randomized to:

Ultrasound every 6 months and AFP vs. control (no screening)

• 37% HCC mortality reduction – mortality rate ratio 0.63 (95% CI 0.41, 0.98)

Zhang BH et al. Randomized controlled trial of screening in hepatocellular carcinoma. J Can Research Clin Oncol. July 2004.

Who should be screened for HCC? AASLD Guidelines

Marrerro et al. Hepatology 68(2) 2018.

Diagnosis• Diagnostic imaging indicated for lesion 1 cm

or greater or AFP > 20

• Typically no biopsy required

• LIRADS scoring system used to characterize lesions

Applies to patients with cirrhosis or chronic hepatitis B infection and incorporates:• Size of arterially enhancing lesion• Washout• Capsule• Threshold growth

• Contrast enhanced multiphase MRI or CT

Burrel et al. Hepatology 2003; 38Marrerro et al. Hepatology 68(2) 2018

LIRADS: Standardized radiology reporting system

LR-1 = definitely benign LR-2 = probably benign

LR-3 = indeterminate LR-4 = suspicious LR-5 = definite

ACR website: derived from LIRADS v2017Separate LIRADS criteria for

Contrast Enhanced Ultrasound exist

HCC: Considerations in staging and selection of therapeutic options

HEPATIC FUNCTION

Cirrhosis?Portal Hypertension?Child Pugh Class of CirrhosisMELD score

TUMOR EXTENT

Intrahepatic vs MetastaticMultifocal?Diffuse-Infiltrative subtypeVascular Invasion?

ECOG PScomorbidities

Hepatocellular Carcinoma: Staging

Multiple Complex staging systems incorporate:• Size• Multifocality• Vascular invasion (e.g. portal vein tumor thrombus)• Underlying liver function (Child-Pugh, MELD)• Performance status• Alpha fetoprotein levels

BCLC (Barcelona Clinic Liver Cancer) Staging

Llovet, JM et al. Design and Endpoints of Clinical Trials in Hepatocellular Carcinoma. Journal of National Cancer Institute. 100: 10, May 21, 2008

Modified BCLC Treatment Algorithm:Early Stage Disease

Figure: EASL CPG HCC. J Hepatol 2018

Early Stage Hepatocellular Carcinoma BCLC Stage 0/A Local Options

Well-preserved liver function (non-cirrhotic, Child-Pugh A amenable to surgery)

• Surgical resection: no specific tumor size cut-off; no vascular invasion• Accepted surgical outcome goal targets include:

• Perioperative mortality 2-3%• 5-year overall survival of 60%

Underlying cirrhosis, poorer baseline liver function• Liver transplantation: Milan criteria; strict eligibility criteria

• Radiofrequency ablation (RFA): Best in tumors < 3 cm; associated with similar survival to surgery.

• Stereotactic Radiation, focal radioembolization and other local interventions promising in multiple phase II trials

Hong SN, et al. Comparing the Outcomes of Radiofrequency Ablation and Surgery in Patients with a Single Small Hepatocellular Carcinoma and Well-Preserved Hepatic Function

Local Treatment for Early Stage HCC: Radiofrequency Ablation

Pre-Radiofrequency Ablation 1-month post-RFA

Images from Dr. Siddharth Padia, UW Interventional Radiology

Early Stage Hepatocellular Carcinoma

• In well-selected patients with early stage HCC, 5-year survival 60-75% with local treatments.(Llovet JM et al. Hepatocellular Carcinoma. Lancet. December, 2003)

• No standard adjuvant chemotherapy following surgical resection, radiofrequency ablation (RFA) or other definitive local therapies

Orthotopic Liver Transplant: MELD Exception Points

Milan Transplant Criteria (1996)

• Strict Criteria• Solitary tumors ≤ 5cm

or• 2-3 tumors all < 1-3 cm

and• No macrovascular

invasion/ mets

New Transplant Criteria (2017)

• Downstaging to Milan allowed• Solitary tumors 5-8 cm• 2-3 lesions

• Each < 5 cm, sum < 8 cm• 4-5 lesions

• Each < 3 cm, sum < 8 cm• AFP Criteria

• AFP > 1000 within Milan require locoregional therapy to achieve AFP < 500

1) Llovet JM et al. Liver transplantation for small hepatocellular carcinoma: the tumor-node-metastases classification does not have prognostic power. Hepatology. June 1998. 2) Kalra A and Biggins SW. New paradigms for organ allocation and distribution in liver transplantation. Gastroenterology volume 34, 2018

Transplantation based on these guidelines has been shown to result in a 5-year post-transplant survival of ~80%

Modified BCLC Treatment Algorithm:Intermediate/Advanced Stage Disease

Figure: EASL CPG HCC. J Hepatol 2018

Intermediate/Advanced Hepatocellular Carcinoma:Standard Approaches

Liver-confined disease (tumors > 5cm, multifocal):• Transarterial embolization (TAE/bland embolization) and chemoembolization

(TACE)

• Radioembolization with Y90 beads (TARE, SIRT)

• External Beam Radiation (SBRT)

• Can be used as ‘bridge’ therapy while awaiting transplant

Metastatic disease or vascular invasion (BCLC C)• Systemic therapy (boards answer); Y90 a consideration in less extensive portal

venous invasion

Hepatocellular Carcinoma: Updated Algorithms

Modified from Marrero et al. Hepatology 68(2); 2018

Systemic Therapy 1st /2nd line

3rd line systemic therapy and beyond

Hepatocellular Carcinoma – Blood Supply to Tumor

Hepatocellular carcinomas derive 95% of their blood supply from branches of the hepatic artery.

Normal liver parenchyma: derives 75% of its blood supply from the portal vein

Radiological Society of North America

Intermediate/Advanced HCC: Transarterial Embolization

Two components of therapy:

1) Acute arterial obstruction2) Local administration of chemotherapeutic agents

Initial Angiogram 6-months post-TACELlovet et al. Lancet 2002 359(9319)

TACE vs. Best Supportive Care – Asian vs. Western Population

Lo et al Hepatology2002

Llovet et al Lancet2002

Etiology 80% Hepatitis B 87% Hepatitis CTumor characteristics 60% multinodular, mean

tumor size 7cm71% multinodular, mean tumor size 5cm

Treatment (TACE) Cisplatin (chemo)Gelatin sponge (embolic)

Doxorubicin (chemo)Gelatin sponge (embolic)

Survival TACE BSC TACE BSC1 year 57% 32% 82% 63%

2 year 31% 11% 63% 27%

3 year 26% 3% 29% 17%

HR for death TACE vs. BSC

HR 0.49 (95% CI 0.28-0.81), p=0.006

HR 0.45 (95% CI 0.25-0.81), p=0.02

Lo C, et al. Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology. May, 2002.

Llovett JM, et al. Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised controlled trial. Lancet. May, 2002

TACE/TAE: Adverse Events

Expected toxicities:

• Post-embolization syndrome: Fatigue, nausea, pain, liver enzyme elevation, low grade fever• Chemotherapy side effects: pancytopenia, alopecia, nausea

Contraindications:• Bilirubin >3 mg/dL• Main portal vein thrombosis – hepatic ischemia

• Child-Pugh C cirrhosis

TACE/TAE – Conclusions and Questions

• Large systematic reviews / meta-analyses have demonstrated a benefit from TACE• Large contemporary series show median OS of 2.5-3.0 years with catheter-based therapy

(Bruix J et al. Chemoembolization for hepatocellular carcinoma. Gastroenterology. November, 2004).

• No definitive advantage of TACE over bland embolization.

• Is TACE/TAE superior to systemic therapy in BCLC B patients?

• How often should TACE/TAE be performed?

• When to move on to systemic therapy?

Y90 Radioembolization: Evolving Segmental Approaches for HCC

Post Y90 Bremsstrahlung Post Y90 Bremsstrahlung

Improved targetingHigher intra-tumoral radiation doses → Improved response?Decreased collateral damage

120 Gy

>500 Gy

0 Gy

High dose localized radioembolization: (radiation segmentectomy)

Padia et al. ASCO 2016 Poster, JCO 34, (suppl. Abstract 4084)

Background: Systemic Therapy for Advanced Hepatocellular Carcinoma

SorafenibSHARP/ASIA PACIFIC

LenvatinibREFLECT TRIAL

Regorafenib (sorafenib tolerant)

RESOURCE

CabozantinibCELESTIAL TRIAL

Nivolumab*CHECKMATE 040

Pembrolizumab*KEYNOTE 224

Ramucirumab (AFP>400) REACH-2

CabozantinibCELESTIAL TRIAL

FDA APPROVED AGENTS1st Line 2nd Line 3rd Line

BCLC B (ineligible/refractory to catheter-based therapy

BCLC C (Vascular Invasion/Metastatic Disease)

*Accelerated Approval based upon

ORR and DORNivolumab + Ipilimumab

CHECKMATE 040

Atezolizumab + Bevacizumab

IMBRAVE150 TRIAL

Advanced/Metastatic Hepatocellular Carcinoma: SHARP Trial

Sorafenib approved by the FDA for advanced HCC in November 2007

Advanced/Metastatic HCC: Sorafenib

Wilhelm et al. Discovery and development of sorafenib: a multikinase inhibitor for treating cancer. Nature Reviews Drug Discovery. October, 2006.

SHARP: Patient Characteristics

Sorafenib (n=299)

Placebo (n=303)

Age 65 66

Male/Female 87/13 87/13

Region (Europe/N. America/Other % 88/9/3 87/10/3

Etiology (HCV/HBV)(Alcohol/Other)

29/1926/26

27/1826/29

Child Pugh (A/B %) 95/5 98/2

Prior Therapies:Surgical resectionLoco-regional therapies

19%39%

21%41%

ECOG PS:O12

54%38%8%

54%39%7%

Vascular Invasion/Extrahepatic spreadPresentAbsent

70%30%

70%30%Llovet ASCO 2007

SHARP Trial: Results

Median survival: 10.7 vs. 7.9 months (HR 0.69 (95% CI 0.55, 0.87) p<0.001

Disease control rate: 43% vs. 32% (p=0.002) – largely stable disease

SHARP Trial: Safety

•Overall incidence of any grade adverse event: 80% (sorafenib) vs. 52% (placebo)

•Grade 3-4 toxicities: Hand-foot syndrome, diarrhea.

•Of note, prophylactic urea-based lotions decrease severity of hand-foot syndrome

Benomar, et al. Dermatology online journal. Nov 2008

Lenvatinib: First-Line HCC Trial

Kudo M, Finn RS, Qin S, et al. Lenvatinib versus sorafenib in first-line treatment of patients with unresectable hepatocellular carcinoma: a randomised phase 3 non-inferiority trial [published online February 9, 2018]. Lancet. doi:10.1016/S0140-6736(18)30207-1.

Lenvatinib First-Line HCC Trial

Lenvatinib non-inferior to sorafenib as 1st line therapy• Multi-TKI: anti VEGF, FGFR, PDGFRα, RET, KIT• FDA approved August 2018 for Child-Pugh A patients• ORR: 24% vs 9% by mRECIST

Kudo M, Finn RS, Qin S, et al. Lenvatinib versus sorafenib in first-line treatment of patients with unresectable hepatocellular carcinoma: a randomised phase 3 non-inferiority trial [published online February 9, 2018]. Lancet.

Lenvatinib: First-Line HCC Trial

Kudo M, Finn RS, Qin S, et al. Lenvatinib versus sorafenib in first-line treatment of patients with unresectable hepatocellular carcinoma: a randomised phase 3 non-inferiority trial [published online February 9, 2018]. Lancet. doi:10.1016/S0140-6736(18)30207-1.

Practice Changing Trial: IMBRAVE 150 TrialAtezolizumab + Bevacizumab for 1st Line HCC

Slide modified from Cheng, AL et al. ESMO ASIA 2019 Oral Presentation

Key Inclusion/Exclusion Criteria

Notable Inclusion Criteria• Child Pugh A hepatic function

• Advanced HCC (not a candidate for surgery or transplant)

• ECOG 0-1

• Extensive portal vein and hepatic venous invasion allowed

• AST/ALT < 5x ULN

• Platelet count >75,000

Notable Exclusion Criteria• Untreated/incompletely treated

esophageal/gastric varices

• History of autoimmune disease

• Hepatitis B/C co-infection

• Anticoagulation or antiplatelet therapy (ASA 81 mg allowed)

• Uncontrolled hypertension (>150/100)

IMBRAVE 150 RESULTS

Finn et al. NEJM 2020 382:1894-1905

Comments:

• Trial stopped at first interim analysis due to clear efficacy

• Met both co-primary endpoints• OS HR 0.58 p<.001• PFS HR .59 p<.001

• mOS not yet reached, longer follow-up needed

• ORR 27.3% vs 11.9%

• Favorable mPFS of 6.8 months

Characteristic (n)Atezo + Bev

mOS, mo(n = 336)

Sorafenib mOS, mo(n = 165) HR (95% CI)a

All patients (501) NE 13.2 0.58 (0.42, 0.79)

Asia (excluding Japanb) (201) NE 13.1 0.53 (0.32, 0.87)

Rest of world (300) NE 13.2 0.65 (0.44, 0.98)

ECOG PS 0 (312) NE 13.9 0.67 (0.43, 1.06)

ECOG PS 1 (189) NE 7.4 0.51 (0.33, 0.80)

BCLC stage Bc (78) NE 14.9 1.09 (0.33, 3.53)

BCLC stage Cc (409) NE 11.4 0.54 (0.39, 0.75)

HBV HCC (240) NE 13.9 0.51 (0.32, 0.81)

HCV HCC (108) NE 13.1 0.43 (0.22, 0.87)

Non-viral HCC (153) NE 14.9 0.91 (0.52, 1.60)

AFP ≥ 400 ng/mL (187) 12.8 9.1 0.68 (0.43, 1.08)

AFP < 400 ng/mL (314) NE 13.9 0.52 (0.34, 0.81)

EHS and/or MVI (378) NE 10.4 0.55 (0.39, 0.77)

No EHS and MVI (123) NE 14.9 0.69 (0.29, 1.65)

NE, not estimable. a Unstratified HR shown for all characteristics except for “All patients,” where stratified HR is shown. b Japan is included in rest of world. c BCLC stage A not shown, as there were only 14 patients; thus, estimation is not meaningful. Data cutoff, 29 Aug 2019; median survival follow-up, 8.6 mo.

OS subgroups

Sorafenib betterAtezo + Bev better1.00.2 2

Slide derived from Cheng, AL et al. ESMO ASIA 2019 Oral Presentation

IMBRAVE 150 - AEs

Finn et al. NEJM 2020 382:1894-1905

Comments:

• Serious Adverse Events increased in Atezo/Bev arm slightly (38% vs. 30.8%)

• No one clear toxicity stands out• Less PPE, severe diarrhea, asthenia

noted

• Gastrointestinal (usually variceal) bleeding rates consistent with known risk

• 7% vs 4.5% overall• Fatal bleeding/Perforation Atezo/Bev

(n=6) vs sorafenib (n=1)

IMBRAVE 150 – Quality of Life Assessments

Finn et al. NEJM 2020 382:1894-1905

SUMMARY: FIRST-LINE SYSTEMIC THERAPY FOR HCC

• Atezolizumab and Bevacizumab represents the favored 1st line therapy for advanced HCC for eligible patients

• Patients require EGD for variceal screening and treatment as indicated prior to initiation of therapy

• In patients with advanced, unresectable HCC with Child-Pugh A cirrhosis, treatment with sorafenib resulted in a 3-month survival benefit compared to placebo.

• Lenvatinib demonstrated non-inferiority to sorafenib as 1st line therapy, with superior response rates, TTP and PFS.

• The benefit/safety of current 1st line therapy for routine use in Child-Pugh B cirrhosis is unclear.

Phase III HCC Trials: Second-Line Therapy Outcomes

Regorafenib (sorafenib tolerant)

RESOURCE 2

Cabozantinib(2nd Line only subgroup)1

CELESTIAL TRIAL

PembrolizumabKEYNOTE-240

Ramucirumab (AFP>400) REACH-2 3

mOS (HR 0.70)

mOS (HR 0.63)

mOS (HR 0.71)

mOS (HR 0.78)

mPFS (HR 0.40)*

mPFS (0.45)

mPFS (HR .043)*

mPFS (0.72)

1. Kelley et al. ASCO 2018 Abstract 4088 2. Bruix et al. Lancet 2017 389(10064):56-66 3. Zhu et al. Lancet Oncology 2019 20(2):282-292

*: mPFS by RECIST 1.1

: denotes active therapy arm

6 mo 10 mo 14 mo

Regorafenib vs. Placebo (2nd line)Positive Phase III Trial Results

• Multi-TKI with broad activity• VEGFR1-3, TIE2• FGFR1, PDGFR-B, KIT, RET• C-RAF, B-RAF

• Key Patient Characteristics• Child Pugh A, ECOG 0-1• Tolerant but progressing on sorafenib

• Design• 2:1 randomized placebo-controlled trial• Regorafenib 160 mg days 1-21 monthly• Primary endpoint: improved OS

• Outcome• mOS 10.6 vs 7.8 months (HR .63, p<.0001)• Grade >3 Toxicity compared to placebo:

• 10% increased HTN• 12% hand-foot syndrome• 4% fatigue• 3% diarrhea

Bruix J et al. Lancet Jan 2017. 389(10064):56-66

FDA approved for second line HCC

Ramucirumab as 2L therapy for HCC(in patients with AFP >400)

Zhu et al. REACH-2 Trial Oral Presentation, ASCO 2018 Annual Meeting

Main Grade 3-4 Toxicities: HTN (12%), Ascites (4%), encephalopathy (3%)

FDA approved as second line therapy if AFP > 400

Cabozantinib in Refractory HCCPositive Phase III Data in 2nd / 3rd line

Randomized Phase III trial of cabozantinib vs. placebo sorafenib refractory / intolerant patients with HCC• 707 patients randomized 2:1 against placebo• 2nd /3rd line therapy; Child-Pugh A• mOS 10.2 vs 8.0 months (HR .76, p=.005)• Not selected based upon c-met status• FDA approved

Abou-Alfa GK et al. GI ASCO 2018 oral presentation; JCO 36:4s Abstr 207

Recent results: KEYNOTE-240 Trial (2nd Line Pembrolizumab vs. Placebo)

Did not meet pre-specified p value of .0174

Did not meet pre-specified p value of .002 at 1st interim analysis

FDA approved 2nd Line irrespective of PD-L1 status despite just missing statistical endpoints in Phase III trial.ORR 18.3% by RECIST 1.1 Median DOR 13.8 months mOS 13.9 months

Finn et al. ASCO 2019 JCO 37(suppl; abstr 4004)

Second-Line Systemic Therapy: CaseProgressive Disease 1 year after sorafenib initiation Scans 2 years after PD1 inhibition

Future Directions/Questions: HCC• Optimal sequencing of currently approved agents unclear

• Especially with no data to guide next steps after atezo/bev 1st line therapy

• Optimizing Immunotherapy approaches

ΤΚΙ + α-PD1/PDL1 (n=100)Lenvatinib + Pembro: 36% ORR

88% DCR, mPFS 8.6 mo.

α-CTLA4 + α-PD1/PDL1 (2nd Line)Nivo(1)/Ipi(3): 32% ORR8% CR; 23-month mOS

Promising combination strategies show high response rates in early phase trials; Phase III 1st line trials ongoing

1. Zhu et al. ASCO 2020 Abstr 45192. Kelley et al ASCO 2020 Abstr 4508.3. Yau et al. ASCO 2019 J Clin Oncol. 2019; 37(suppl) Abstr 4012

One Priming Dose α-CTLA4 + α-PDL1Tremelimumab + Durvalumab

Phase II: SBRT + PD1 inhibitor (NCT03316872)Phase II: Radioembolization + PD1 inhibitor (NCT03099564)Phase III: TACE + PD-L1 inhibitor (+/- Bevacizumab) (NCT03778957)

Pembrolizumab Y90 Pembrolizumab• HCC not amenable to

Resection/Transplant

• No prior radioembolization

• Child Pugh A, ECOG 0-1

• BCLC Stage B/C

Ongoing phase 2 Single arm Pilot study (n=30), 3 institution study

Outcomes:Immunologic correlatesToxicity assessmentResponse rates, mOS, TTP

Future Directions: Local Interventions + Immune Checkpoint Inhibition

Future Directions: Adoptive T-cell TherapyAFP-directed chimeric T-cell Receptor Therapy (TCR)

• Advanced HCC, any-line• Child Pugh A• ECOG 0-1• HLA-A*02:01 + (~35%)• Tumor AFP + by IHC (~40%)

or elevated serum AFP• Liver Parenchyma AFP – by

IHC (most)

• Mandatory biopsies• Requires chemotherapy

conditioning

Cell Manufacturing

Leukapheresis

Study Eligibility

Confirmation Screening

TCell

Infusion Post Infusion assessments

Long Term Follow-Up

Every 6 Months for 5 years &

Yearly for up to 15 years

Lymphodepletion

AFP & HLAConfirmation

Days-7 to -5

Day1

Days1- 7

Once Weekly Weeks 2-4 Weeks

8, 12, 16 & 24

Every 3 Months Until completion of interventional phase or withdrawal

CT or MRI at Weeks 4, 8, 16, 24 and then every 3 months

until progression

Hospitalized

Days7, 9 & 11

ScreeningPhase

InterventionalPhase

Long Term Follow-Up Phase

21-28 Days

First in Human Studies, currently accruing

HCC: Final Take-home messages• Localized therapy and liver transplantation for early stage disease (BCLC stage A) can be curative

• For Child-Pugh A/B unresectable HCC (without vascular involvement or metastatic disease): TACE has been shown to prolong survival compared with best supportive care

• For vascular involvement/metastatic HCC or select patients with bulky intermediate stage disease (Child-Pugh A), atezolizumab and bevacizumab is standard of care as first-line therapy.

• For advanced/metastatic HCC (Child-Pugh B), the benefit of systemic therapy is less defined but may be considered in select patients.

• Multiple recently FDA approved systemic therapies in the refractory setting, with no current consensus regarding optimal selection. Many GI Oncologists would attempt TKI (Lenvatinib, sorafenib) after atezo/bev.